The well known propensity of children to place small objects in their mouths leads occasionally to their attempting to swallow them. If the object is small and smooth, it will often pass down the esophagus into the stomach and be passed naturally.

The structure of the esophagus, with its narrowing from the laryngo-pharynx to its normal calibre produces a point about on a level with the sternal ends of the clavicles at which some of these objects tend to become engaged. Accordingly, in considering foreign bodies of the esophagus we find that they usually become caught in its upper part about one to two inches below a line drawn through the larynx. Pennies, which constitute a large proportion of these cases, usually pass into the stomach in children over the age of three years. In children from a year and a half to three years of age, pennies usually engage at the place just described.

The clinical symptoms of such a case are usually quite characteristic. The history is given of a foreign body in the

*Read at the meeting of the Michigan State Medical Society in Kalamazoo, Sept., 1909.

mouth; a period of choking, succeeded by quiet respiration, and the inability to swallow solid food. Water and milk, however, are usually taken with more or less difficulty. The use of the Roentgen ray in the diagnosis of foreign bodies has been attended with usually very brilliant results. It demonstrates at once the presence or absence of the foreign body, the approximate size, and the exact location.

The diagnosis having been established, the question of removal of the obstruction then becomes important. Long forceps, with varying curves and ingenious handles, have been used. The difficulty, however, of differentiating between grasping a foreign body and the membrane of the esophagus is considerable. The old umbrella probang with its harsh. bristles, is very liable to tear off a strip of mucous membrane, with a resultant structure. The writer remembers seeing this instrument used some ten years ago with the result of pulling out a long strip of mucosa, and the patient condemned to have a bougie passed afterwards at regular intervals to keep the stricture dilated.

Case 1. L, aged 3 years, illustrates the former difficulties of diagnosis and removal. This patient was seen during a period of six weeks by fourteen different physicians, some of whom thought he had a quarter in his esophagus, and and some thought he did not. The Ray at once established the diagnosis, but the prolonged attempt at removal with forceps by several laryngologists were followed by pneumonia, which resulted fatally. In this case, perhaps, the prolonged pressure of the coin may have produced an ulceration into the trachea or mediastinum.

Case 2, a horn button, which had been in the esophagus for forty-eight hours, with no dyspnea, but inability to swallow solid food, was followed by failure at removal with the old style forceps. Accordingly, the consulting surgeon incised down to the esophagus, but without opening it, and was able to push the button past the point of constriction, so that it was carried along by the muscular contracture to the stomach.

Case 3. Patient was 21⁄2 years, gave the characteristic clinical history of a coin at the upper end of the esophagus, which was confirmed by the Roentgen Ray. The esophagoscope was used under ether anesthesia, and the coin was distinctly seen. Unfortunately, however, at the operation, the proper forceps was not provided, so that while the coin could be distinctly seen through the esophagoscope, we were unable to remove it. Accordingly a long probe was passed and the coin pushed on to the stomach, after which it was passed by rectum in five days, with no disturbance to the patient. The roentgenogram of this case shows first the point of lodgment, second the coin part way down the esophagus, and third the coin in the stomach.

head and neck in the proper position, considerable difficulty was found in passing the esophagoscope. After several attempts, however, it was passed and the coin seen and at once removed. The clinical history of this case was more eventful. Forty-eight hours after the operation the patient was taken with an obstructive swelling of the upper trachea which necessitated intubation. The intubation tube was worn for four days, and then removed, after which the little patient made a prompt recovery.

Case 6. C. W., aged 3 years, referred by Dr. Sherrill, gave a history of swallowing a coin two days before. The Ray showed its lodgment in the accustomed location. The penny was removed easily by the aid of the Jackson Tube.

Case 7.-G. P., aged 6 years, was brought to Harper Hospital with a history of having swallowed a button four days previously. There was complete occlusion of the esophagus, the patient being unable to swallow fluid or solid food. The father of the little patient brought a button similar to the one which the child had swallowed. Before X-Raying the child, we decided to find out if the button would cast enough shad ow to show. Accordingly an experimental plate was made of the hand of the father with the known button underneath. It was found that the density of the button was not sufficient to cause any shadow which would be diagnostic upon the plate. Accordingly the esophagoscope was at once introduced, the button found in the upper part of the esophagus and removed. In this case, although the button had been lodged for four days, there was no after-inflammatory reaction.

Foreign bodies in the trachea and bronchi are more serious in their effects,

Case 4. C. E., aged 2 years, referred by Dr. Gorenflo, was found by the aid of the Roentgen Ray to have a penny in the esophagus. Under ether anesthesia the esophagoscope was introduced, the coin grasped with the forceps, and immediately removed. Subsequent clinical history uneventful.

Case 5. E. W., aged 21⁄2 years, was found to have a penny in the upper esophagus, which had been lodged only a few hours. Owing to the fact that the assistant who held the head at the operation was inexperienced in keeping the

Case 8. F. B., aged 9 months, referred by Dr. Sheets, had a clinical history of putting a piece of eggshell in the mouth, followed by severe choking. The child was able to take milk from. the bottle with some difficulty. The breathing was loud and stridulous, resembling the dyspnea of a laryngeal diphtheria. Several plates were made, but owing to the constant crying of the child during the exposure, the plates were unsatisfactory. The Jackson speculum was introduced under chloroform anesthesia, and the pieces of egg shell were found embedded between the vocal cords. After removal, the child was